Step Therapy Protocol Exception Requests
(a) A health benefit plan issuer shall establish a process in a user-friendly format that is readily accessible to a patient and prescribing provider, in the health benefit plan’s formulary document and otherwise, through which an exception request under this section may be submitted by the provider.
(b) A prescribing provider on behalf of a patient may submit to the patient’s health benefit plan issuer a written request for an exception to a step therapy protocol required by the patient’s health benefit plan. The provider shall submit the request on the standard form prescribed by the commissioner under Section 1369.304.
(c) A health benefit plan issuer shall grant a written request under Subsection (b) if the request includes the prescribing provider’s written statement, with supporting documentation, stating that:
(1) the drug required under the step therapy protocol:
(A) is contraindicated;
(B) will likely cause an adverse reaction in or physical or mental harm to the patient; or
(C) is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen;
(2) the patient previously discontinued taking the drug required under the step therapy protocol, or another prescription drug in the same pharmacologic class or with the same mechanism of action as the required drug, while under the health benefit plan currently in force or while covered under another health benefit plan because the drug was not effective or had a diminished effect or because of an adverse event;
(3) the drug required under the step therapy protocol is not in the best interest of the patient, based on clinical appropriateness, because the patient’s use of the drug is expected to:
(A) cause a significant barrier to the patient’s adherence to or compliance with the patient’s plan of care;
(B) worsen a comorbid condition of the patient; or
(C) decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; or
(4)(A) the drug that is subject to the step therapy protocol was prescribed for the patient’s condition;
(B) the patient:
(i) received benefits for the drug under the health benefit plan currently in force or a previous health benefit plan; and
(ii) is stable on the drug; and
(C) the change in the patient’s prescription drug regimen required by the step therapy protocol is expected to be ineffective or cause harm to the patient based on the known clinical characteristics of the patient and the known characteristics of the required prescription drug regimen.
(d) Except as provided by Subsection (e), if a health benefit plan issuer does not deny an exception request described by Subsection (c) before 72 hours after the health benefit plan issuer receives the request, the request is considered granted.
(e) If an exception request described by Subsection (c) also states that the prescribing provider reasonably believes that denial of the request makes the death of or serious harm to the patient probable, the request is considered granted if the health benefit plan issuer does not deny the request before 24 hours after the health benefit plan issuer receives the request.
(f) The denial of an exception request under this section is an adverse determination for purposes of Section 4201.002 and is subject to appeal under Subchapters H and I, Chapter 4201.